The knees are responsible for bearing the entire body’s weight and making movement possible. They are also one of the most complex joints in the body. It’s no surprise that knee pain is one of the most common medical complaints. Because of the complexity of the knee joint, successfully treating knee pain can be difficult. Knee injuries are common. There are also many different medical conditions that can cause knee pain, from autoimmune disorders to degenerative diseases. For the most successful knee pain management action pain, it’s important to figure out the root cause of the pain and tailor a treatment plan that works specifically for you and your pain.
Where does knee pain management start?
For many people experiencing chronic knee pain, surgery is not a desired treatment option. Knee surgery requires a lengthy period of rehabilitation and does not offer guaranteed relief. Still others may not be good candidates for knee surgery because of age or other factors. Worse, up to 20% of patients who undergo total knee arthroplasty continue to experience pain after knee replacement surgery, according to a paper in Pain Medicine News by Dr. Paul Lynch. Many of these patients grow understandably frustrated by the seeming dead-end of treatment options.
Fortunately, pain management alternatives to surgery are readily available. Patients who elect against surgery or who are not good candidates for a procedure have a variety of comprehensive knee pain management options. These include physical therapy, medications, and alternative treatments such as acupuncture that we’ll discuss in more depth throughout this post.
The exact mix of workable alternative therapies varies by patient and requires a doctor willing to explore all avenues. Many therapies are still emerging, but have an increasing number of clinical studies supporting their efficacy.
The anatomy of the knee
Chronic knee pain is a very common condition. The knee is one of the largest and most complex joint in the body. It is comprised of different bones, ligaments, muscles, and tendons as well as cartilage that provides a protective covering for the knee joint. There are four bones in the knee. These are the femur, tibia, fibula, and patella. These bones are connected to each other through ligaments such as the:
- Anterior cruciate ligament (ACL) that prevents the femur from slipping backward onto the tibia
- Posterior cruciate ligament (PCL) that prevents the femur from slipping forward onto the tibia
- Medial and lateral collateral ligaments that prevent the femur from moving sideways
Several nerves are also associated with the knee, including the femoral nerve. This is connected to the muscles associated with straightening the leg. There is also the sciatic nerve, which begins in the lower back and runs down the leg. From these two main nerves, a variety of smaller nerves branch off and give the entire knee sensation.
Knee pain causes
Pain can result when these nerves over-fire, telling the brain there’s tissue damage even if none exists or it healed long ago. Pain levels may vary from mild to severe, and sensation can originate from one or several nerves located in the knee. Knee pain causes may also include:
- Lingering discomfort from injuries
- Patellofemoral pain syndrome
- Iliotibial band syndrome
The following video gives a more in-depth overview of the causes of knee pain, while the Arthritis Foundation gives more information about treating knee pain caused by arthritis.
The first step to knee pain management is diagnosis
At Pain Medicine News, Dr. Paul Lynch describes a thorough exam process to diagnose the source of knee pain. Dr. Lynch stresses the importance of a thorough diagnostic exam to find the source of the knee pain. The exam should assess whether or not the individual has any deformities, swelling, or skin infection. Also, the physician can perform several provocative exam maneuvers. These exam maneuvers are manipulations of the leg by the physician, which can aid in assessing the specific location and source of knee pain.
Additionally, a thorough history from the pained individual is important. The patient history should include:
- Duration of painful symptoms
- Factors that alleviate or exacerbate the symptoms
- Previous knee pain management interventions and their outcomes
- Associated pain in the back or hips
If the physical exam and patient history suggest a bone-related source for the knee pain, Dr. Lynch suggests an X-ray of the knee. If the soft tissue, such as cartilage or ligaments, is suspected as the source of the knee pain, Dr. Lynch instead suggests an ultrasound or magnetic resonance imaging (MRI) scan. For individuals whose knee pain seems to be referred pain from the hip or back, further imaging tests should be conducted of those regions, too. Electrodiagnostic studies might also be called for, if the knee pain seems to be nerve-related.
According to Dr. Lynch:
“Correlating the patient’s symptoms and the physical exam findings with abnormal diagnostic test results can help to condense the differential diagnosis and aid in tailoring a treatment plan.”
Creating your knee pain management action plan
After a diagnosis has been reached, the physician can then form an individual knee pain management plan for that specific patient. The most effective knee pain management plans combine lifestyle interventions with comprehensive, interventional treatments, including alternative therapies and innovative, minimally-invasive procedures.
Pain has a huge emotional component, with stress and depression exacerbating or sometimes causing pain while pain can also lead to stress and depression. Because of the intricate relationship, many patients find relaxation techniques such as meditation or biofeedback, which involves learning how to control body systems such as heart rate and blood pressure, helpful in managing chronic knee pain.
Additionally, exercise is critical for knee pain patients. Focus on low-impact, consistent movements that have been approved by your doctor. An exercise program can relieve knee pain at its source and prevent future injuries. Appropriate knee pain exercises may include:
- Tai chi
- Knee-strengthening exercises
For acute injuries, your doctor may also recommend a regimen of hot and cold therapy, as well as rest to relieve your pain. They may also recommend taking over-the-counter medications to control swelling and pain.
For more advanced forms of knee pain, many patients’ knee pain management plans will also include a course of physical therapy, chiropractic visits, or a prescription for durable medical equipment (DME).
Physical therapy may help patients rebuild strength in muscles that support the knee, including the quadriceps, and improve mobility. A study published in the New England Journal of Medicine found that physical therapy offered patients with meniscus tears and arthritis in the knee as much relief as surgery.
Visiting a chiropractor may also help a patient find proper skeletal alignment that reduces knee pain. Other patients may find DME—such as crutches or braces—helpful for improving mobility and quality of life.
Interventional knee pain management
If these less-invasive therapies are unsuccessful at reducing knee pain, pain doctors typically advise for a phase of interventional treatments before resorting to surgery. This second phase of treatments includes various ways to block the knee’s pain signals. Several interventional therapies are gaining ground for knee pain management.
Because some interventional procedures involve careful placement of needles, it’s important that your pain doctor choose the correct image guidance system.
When an interventional technique involves an injection, placing the needle correctly is vital. These techniques might include the delivery of medications, plasma, or stem cells, and incorrect placement of the injection can increase knee pain. Therefore, most physicians utilize either ultrasound or fluoroscopy to ensure correct placement of injections.
Fluoroscopy works well for intraarticular injections, which are injections delivered directly into the knee joint. This is because fluoroscopy provides excellent visualization of the joint. Also, if the individual receiving treatment has had a total knee joint replacement surgery in the past, the hardware used in joint replacement can be effectively visualized with fluoroscopy. However, use of fluoroscopy imaging exposes the person under treatment to some radiation.
If the physician needs to better visualize the soft tissues of the knee, ultrasound is more effective. Additionally, because ultrasound imaging is real-time and easily adjusted to allow for the best possible visualization, it can be effective for both intraarticular and extraarticular (delivered outside the knee joint itself) injections. Because ultrasound imaging is so easily manipulated, however, it’s user-dependent, which leads to variations in its effectiveness.
For example, a nerve block injection is the delivery of an anesthetic, such as lidocaine, directly to a nerve. Careful diagnosis will help the physician decide the exact placement of a nerve block injection, and there are several potential locations that can reduce nerve pain. The saphenous, femoral, lateral femoral, lumbar, and genicular nerves are all potentially effective placements. Nerve block injections are minimally-invasive, out-patient procedures, and they sometimes provide immediate pain relief.
Steroid knee injections
Intra-articular steroid injections are clinically shown to reduce pain levels. These injections involve steroids injected directly into the knee. A study published in Arthritis and Rheumatology found patients who received the injections experienced lower pain levels and less joint stiffness than a control group receiving saline.
Hyaluronic acid knee injections
Intra-articular knee joint injections of hyaluronic acid have also been clinically shown to mitigate knee pain. Hyaluronic acid is present naturally in the body and helps to lubricate the joints, keeping them operating smoothly and without pain. When people develop osteoarthritis in the knee, the hyaluronic acid surrounding the joint. Some patients experience pain relief after receiving injections of the acid.
A study in Arthritis Research and Therapy found that hyaluronic acid injections are as effective as non-steroidal anti-inflammatory drugs (NSAIDs). Researchers divided 200 patients into a control group that took NSAIDs three times daily for five weeks and an experimental group that received hyaluronic acid injections once each week for 5 weeks.
Both groups reported reduced pain levels and improved joint mobility while the hyaluronic acid group experienced fewer side effects than the NSAID group.
Regenerative knee pain management
Other types of injections feature medical technology that holds promise for revolutionizing knee pain management. Doctors are now increasingly injecting mesenchymal stem cells, which come from adult bone marrow, into the knee to help regenerate tissue and cartilage and reduce inflammation. These stem cells may come from a patient’s own bone marrow or an adult donor. Stem cells are able to differentiate into various types of cells, and the stem cells injected into a joint are specifically chosen for their ability to differentiate into connective tissues like cartilage.
Another potential treatment for chronic knee pain is platelet rich plasma (PRP) therapy. Platelets found in blood contain what’s known as growth factors that help tissue regenerate.PRP can stimulate the growth of connective tissues. Cartilage in the knees acts as a shock absorber and allows smooth joint movement, so loss of cartilage can cause painful grinding and scraping of bones.
PRP involves a doctor drawing blood from a patient and placing it in a special machine called a centrifuge, which spins the blood rapidly to separate the platelets. The doctor then injects the platelets into the patient’s knee to encourage healing and pain reduction. Injections of stem cells or platelet-rich plasma aim to replace lost cartilage, thereby reducing pain.
You can see how any of these knee joint injections take place in the video below.
If an individual has undergone a nerve block injection and experienced pain relief from it, radiofrequency ablation (RFA) can then be performed. Radiofrequency ablation is the careful application of radio waves, which produce electricity and heat. This heat is targeted to the nerve causing the knee pain, which damages the nerve and disrupts pain signals.
If a previous nerve block has successfully reduced pain, the physician can be sure which nerve is sending pain signals and apply radiofrequency ablation to that nerve.
Another way to block pain signals utilizes electrical stimulation of nerves to interrupt the transmission of the signals. Spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) both use this method.
Spinal cord stimulation involves the placement of a small implant in the spine of the individual being treated. The individual is then given a remote control that controls the release of electrical signals. This interrupts the pain signals being transmitted along the nerve. Similarly, peripheral nerve stimulation is the implantation of a small device, controlled by a remote, that transmits an electrical signal to block pain. In peripheral nerve stimulation, though, the implant is placed near a peripheral nerve, or a nerve that is not in the spinal column.
Because spinal cord stimulation and peripheral nerve stimulation involve implants, they are slightly more high-risk than other interventional procedures. Therefore, both spinal cord stimulation and peripheral nerve stimulation are completed in two procedures. During the first procedure, temporary electrodes will be implanted for a test period, usually lasting about a week. If the test period is successful, a permanent device will be implanted.
Your knee pain management action plan will likely include a combination of these lifestyle and interventional treatments before you find relief. If you’re ready to talk to a doctor today about your own knee pain management action plan, click the button below to get started.